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Epistaxis (Nosebleed)

Acute bleeding from the nasal cavity caused by ruptured Kiesselbach plexus, posterior nasal arteries, or systemic bleeding diatheses requiring graded management from local pressure and topical vasoconstrictors to nasal packing, cautery, and endovascular embolization.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our KBB (Kulak Burun Boğaz) department. Book Appointment →

What is Epistaxis (Nosebleed)?

Epistaxis is acute hemorrhage from the nasal mucosa, classified anatomically as anterior (Little's area / Kiesselbach plexus on the anteroinferior septum, 90% of cases) or posterior (Woodruff plexus, sphenopalatine artery branches, 10%, more severe). The Kiesselbach plexus receives anastomoses from anterior ethmoid (ophthalmic), sphenopalatine (maxillary), greater palatine, and superior labial (facial) arteries. Posterior bleeding originates from the sphenopalatine artery and posterior ethmoid artery branches.

Etiology includes local factors (digital trauma, dry air, septal deviation, foreign bodies, neoplasms, juvenile nasopharyngeal angiofibroma in adolescent males, hereditary hemorrhagic telangiectasia / Osler-Weber-Rendu) and systemic factors (hypertension, anticoagulation including warfarin/DOACs/antiplatelets, coagulopathy, thrombocytopenia, renal failure, alcohol). Initial evaluation includes vital signs, hemoglobin, coagulation studies, and identification of bleeding source by anterior rhinoscopy or nasal endoscopy.

Stepwise management progresses from first aid (lean forward, pinch nasal alae for 10-15 minutes, ice pack), topical vasoconstrictors (oxymetazoline, lidocaine-epinephrine), silver nitrate or electrocautery for visible anterior bleeders, anterior packing (Merocel, Rapid Rhino, traditional ribbon gauze with petroleum) for diffuse anterior bleeding, posterior packing (Foley catheter, Epistat) for posterior bleeding, and surgical/endovascular intervention (endoscopic sphenopalatine artery ligation, anterior ethmoid artery ligation, transarterial embolization) for refractory cases.

Symptoms

Active bleeding from one or both nostrils
Sensation of blood draining into the throat (posterior bleeding)
Blood-streaked sputum or hematemesis
Lightheadedness, palpitations (significant blood loss)
Hypotension and tachycardia (severe hemorrhage)
Recurrent self-limited episodes (HHT, anticoagulation)
Crusting, dryness on examination

Risk Factors

Anticoagulant or antiplatelet therapy
Uncontrolled hypertension
Dry environment, low humidity, winter season
Septal deviation, septal perforation
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu)
Coagulopathy, thrombocytopenia, liver/renal disease
Nasal trauma, digital manipulation, intranasal drug use
Sinonasal neoplasm, juvenile nasopharyngeal angiofibroma

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Bleeding not controlled after 15-20 minutes of compression
  • Heavy or recurrent bleeding episodes
  • Bleeding with anticoagulation requiring INR check
  • Lightheadedness, syncope, signs of significant blood loss
  • Bleeding after nasal trauma or surgery
  • Posterior bleeding (blood draining into throat)
  • Recurrent unilateral bleeding (rule out neoplasm)

Treatment Methods

01
First aid: forward lean, alae compression 10-15 minutes, ice
02
Topical oxymetazoline ± lidocaine-epinephrine pledget
03
Silver nitrate or electrocautery of anterior bleeding point
04
Anterior nasal packing (Merocel, Rapid Rhino) 24-48 hours
05
Posterior packing (Foley catheter, Epistat) for posterior bleeding
06
Endoscopic sphenopalatine artery ligation (refractory posterior)
07
Anterior ethmoid artery ligation (severe upper septal bleeding)
08
Transarterial embolization (internal maxillary artery) for refractory cases
09
Reverse anticoagulation if appropriate; manage hypertension
10
HHT-specific: bevacizumab, septodermoplasty, laser ablation

Which Department to Visit?

You can visit our KBB (Kulak Burun Boğaz) department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.